PREVENTIVE
MEDICINE
FORUM:
6, l-3 (1977)
PREVENTIVE
MEDICINE PLANNING
AND POPULATION
Introduction CHARLES Division
of Epidemiology,
B. ARNOLD
American Health Foundation, 1370 Avenue of the Americas, New York, New York 10019
The specter of unchecked world population growth overshadows almost all other contemporary human problems. Its rational solutions, if such exist, involve human engineering that is unprecedented in its scope and complexity. On a global basis it represents an effort to alter the reproductive behavior of perhaps 650 million fertile women in over 100 countries. By the year 2000, this number will have increased to 1.2 billion women. Much controversy exists over nearly every step in the development of comprehensive strategies ranging from the national political level down to factors governing the participation of individual couples. Yet, over the past 16 years, much has been learned from demographic data and program evaluations about population problems and the prospects for eventual control. The spectrum of concerns encompassed by preventive medicine inevitably involves it in population growth. In this Forum, we touch on some of these concerns. However, preventive medicine’s responsibilities go beyond evincing interest in plights of mankind with health implications. Among its principal responsibilities is the development of alternate strategies for coping with complex problems associated with human biology, such as population. In this Forum, for example, Simmons asks: Can economic development be regarded as a substitute for population control programs? It becomes clear, as one follows Simmons’ careful review of the demographic and economic factors, that no simple answer can be produced to such a question. In all likelihood, as he shows, economic development is not a substitute for population control programs, but slowed population growth alone probably cannot elevate a nation’s socioeconomic development, if the latter is at a comparatively low level when a population control program begins. What can history teach us about population growth? Omran and others in recent years have examined the comparative development of various societies in order to determine what Omran calls the concept of “The Epidemiological Transition”. Following a review of the mortality, morbidity, and fertility patterns of the United States over the past 100 years, Omran draws two interesting conclusions: (1) social change in the U.S. probably preceded political and technical change; and (2) the kind of epidemiological transition undergone by Western societies may be inapplicable to developing ones in the 20th century. Copyright All rights
0 1977 by Academic Press, Inc. of reproduction in any form reserved.
ISSN 0691.7435
2
IN?‘RODUC1‘ION
In human biology, the cell is the fundamental unit studied by scientists concerned with physiology. In populations, the most fundamental social unit is the family. Just as no sound knowledge of human biology can proceed without an understanding of cellular response to its environment, David and Johnson examine the environmental and intrinsic properties of the family in the context of population growth. They point out the complex social forces that interact with the family unit. From this interaction, fertility choices are made that seem affected by psychological, microeconomic, and cultural factors. A dynamic societal process seems clearly established once fertility begins to decline. Maternal and child health improves. Parents, particularly mothers, spend less time on preschool child care. Women begin to seek activities outside the family, particularly in the work force. Conjugal relationships change, especially redefinition of family tasks formerly relegated to one sex or the other. As intervals between births lengthen, birth rates usually begin to decline. If protein nutrition and total calorie consumption is maintained at an adequate level, social indicators of intellectual achievement will probably begin to improve. From a nexus of such logical and established facts, we begin to link David and Johnson’s ideas with those of Omran and Simmons. That is, economic development, the epidemiological transition, and fertility behavior are (in actuality) closely linked concepts. The conceptual integrity of the underlying concepts aside, one must consider the problems associated with providing contraceptive services to diverse population groups. Marshall poses a question whose answer seems obvious, and yet underscores a critical weakness in many preventive care programs: Do we tit the people to the technology, or the technology to the people? By describing a multinational investigation by the World Health Organization, he indicates the way applied social science is tackling the immense problem of contraceptive acceptability in developing societies. Marshall conveys the need for contraceptive service providers to search the assumptions underlying their programs. In the answers to these inner-directed questions, aided by the WHO study, may lie vastly improved, personally oriented strategies for family planning. While it seems that several European countries controlled their fertility successfully prior to the advent of modern contraceptive technology, effectively providing family planning services should make the family’s task easier when smaller families or increased length of birth intervals become desirable objectives. In his article, Perkin reviews the alternatives available for family-planning-service delivery systems, particularly with application to developing societies. As he comments, the results from several societies are most encouraging. Family planning services are becoming well managed. Contraception is receivmg increased acceptability from peoples introduced to modern technology comparatively recently. In the final analysis, however, in democratic societies, policy makers must help change social institutions so that they are responsible to people’s needs. The political process, one need not be reminded, has its own complexities. Decision making at the highest levels of state encounters various competing alternatives. It must often be balanced against intensely held local issues; it ranges to international pressures, often of an overriding nature for developing nations. In such an environment, it may seem remarkable that anything can be decided. However, as
INTRODUCTION
3
Measham describes, these pressures can occasionally be\ rer clarify complex issues. For example, the 1974Bucharest world population conference, while acting as an arena for various national polemic exercises, helped bring understanding of population issues and policy alternatives to leaders of many nations who had previously not given them much attention. The conference decisions were difficult to accept for some Western observers. Further, the decisions may have been useful not because of what was decided, but simply because many heretofore uninitiated policy makers participated in a process with population as the endpoint. In this Forum we endeavor to describe and clarify a variety of issues central to one of the greatest problems ever faced by mankind. As the articles attest, the issue before preventive medicine would not seem to be whether we have the knowledge sufficient to understand the problems, but rather whether we have the collective wisdom to act on what we know.
MEDICINE
FORUM:
6, l-3 (1977)
PREVENTIVE
MEDICINE PLANNING
AND POPULATION
Introduction CHARLES Division
of Epidemiology,
B. ARNOLD
American Health Foundation, 1370 Avenue of the Americas, New York, New York 10019
The specter of unchecked world population growth overshadows almost all other contemporary human problems. Its rational solutions, if such exist, involve human engineering that is unprecedented in its scope and complexity. On a global basis it represents an effort to alter the reproductive behavior of perhaps 650 million fertile women in over 100 countries. By the year 2000, this number will have increased to 1.2 billion women. Much controversy exists over nearly every step in the development of comprehensive strategies ranging from the national political level down to factors governing the participation of individual couples. Yet, over the past 16 years, much has been learned from demographic data and program evaluations about population problems and the prospects for eventual control. The spectrum of concerns encompassed by preventive medicine inevitably involves it in population growth. In this Forum, we touch on some of these concerns. However, preventive medicine’s responsibilities go beyond evincing interest in plights of mankind with health implications. Among its principal responsibilities is the development of alternate strategies for coping with complex problems associated with human biology, such as population. In this Forum, for example, Simmons asks: Can economic development be regarded as a substitute for population control programs? It becomes clear, as one follows Simmons’ careful review of the demographic and economic factors, that no simple answer can be produced to such a question. In all likelihood, as he shows, economic development is not a substitute for population control programs, but slowed population growth alone probably cannot elevate a nation’s socioeconomic development, if the latter is at a comparatively low level when a population control program begins. What can history teach us about population growth? Omran and others in recent years have examined the comparative development of various societies in order to determine what Omran calls the concept of “The Epidemiological Transition”. Following a review of the mortality, morbidity, and fertility patterns of the United States over the past 100 years, Omran draws two interesting conclusions: (1) social change in the U.S. probably preceded political and technical change; and (2) the kind of epidemiological transition undergone by Western societies may be inapplicable to developing ones in the 20th century. Copyright All rights
0 1977 by Academic Press, Inc. of reproduction in any form reserved.
ISSN 0691.7435
2
IN?‘RODUC1‘ION
In human biology, the cell is the fundamental unit studied by scientists concerned with physiology. In populations, the most fundamental social unit is the family. Just as no sound knowledge of human biology can proceed without an understanding of cellular response to its environment, David and Johnson examine the environmental and intrinsic properties of the family in the context of population growth. They point out the complex social forces that interact with the family unit. From this interaction, fertility choices are made that seem affected by psychological, microeconomic, and cultural factors. A dynamic societal process seems clearly established once fertility begins to decline. Maternal and child health improves. Parents, particularly mothers, spend less time on preschool child care. Women begin to seek activities outside the family, particularly in the work force. Conjugal relationships change, especially redefinition of family tasks formerly relegated to one sex or the other. As intervals between births lengthen, birth rates usually begin to decline. If protein nutrition and total calorie consumption is maintained at an adequate level, social indicators of intellectual achievement will probably begin to improve. From a nexus of such logical and established facts, we begin to link David and Johnson’s ideas with those of Omran and Simmons. That is, economic development, the epidemiological transition, and fertility behavior are (in actuality) closely linked concepts. The conceptual integrity of the underlying concepts aside, one must consider the problems associated with providing contraceptive services to diverse population groups. Marshall poses a question whose answer seems obvious, and yet underscores a critical weakness in many preventive care programs: Do we tit the people to the technology, or the technology to the people? By describing a multinational investigation by the World Health Organization, he indicates the way applied social science is tackling the immense problem of contraceptive acceptability in developing societies. Marshall conveys the need for contraceptive service providers to search the assumptions underlying their programs. In the answers to these inner-directed questions, aided by the WHO study, may lie vastly improved, personally oriented strategies for family planning. While it seems that several European countries controlled their fertility successfully prior to the advent of modern contraceptive technology, effectively providing family planning services should make the family’s task easier when smaller families or increased length of birth intervals become desirable objectives. In his article, Perkin reviews the alternatives available for family-planning-service delivery systems, particularly with application to developing societies. As he comments, the results from several societies are most encouraging. Family planning services are becoming well managed. Contraception is receivmg increased acceptability from peoples introduced to modern technology comparatively recently. In the final analysis, however, in democratic societies, policy makers must help change social institutions so that they are responsible to people’s needs. The political process, one need not be reminded, has its own complexities. Decision making at the highest levels of state encounters various competing alternatives. It must often be balanced against intensely held local issues; it ranges to international pressures, often of an overriding nature for developing nations. In such an environment, it may seem remarkable that anything can be decided. However, as
INTRODUCTION
3
Measham describes, these pressures can occasionally be\ rer clarify complex issues. For example, the 1974Bucharest world population conference, while acting as an arena for various national polemic exercises, helped bring understanding of population issues and policy alternatives to leaders of many nations who had previously not given them much attention. The conference decisions were difficult to accept for some Western observers. Further, the decisions may have been useful not because of what was decided, but simply because many heretofore uninitiated policy makers participated in a process with population as the endpoint. In this Forum we endeavor to describe and clarify a variety of issues central to one of the greatest problems ever faced by mankind. As the articles attest, the issue before preventive medicine would not seem to be whether we have the knowledge sufficient to understand the problems, but rather whether we have the collective wisdom to act on what we know.
